When to know rather or not a mitral valve needs replcaing

[pms_barbie]

Hello and thanks for taking my question.  I asked my local cardiologist when they would know my mitrl vavle needed  replacing.  The four things he said were heart enlargement naturally.  If I went into atrial fib.  Swelling of the ankles and feet and congestion in the lungs.  My question is isnt it already past the point of replacement if the hearts enlarged and your into atrial fib?  I mean shouldnt  sever reg be enough to warrnt a replacement or repair?    There seems to be some controversy over why I have mvp one drs says plain old mitral vavle prolapse another says rhuematic fever at some point in time.  I know no one wants to hear about pvcs but I already suffer from them and I sure dont want another rhythm problem on top of them.  I am curios as to the criteria for a repair versus a replacement.  My local cardio said if I could find a good surgeon its possible they could repair mine.  I have mvp and thickening of bothe the leaflets.  Any help would be greatly appreciated.

[va_tony]

Thanks for your input. No, I've never had a TEE.  It sounds positively awful but I guess I should try to arrange one, if for no other reason than to reassure myself that I don't need immediate valve repair.

I have been going to my cardiologist for nearly twenty years, before 2 1/2 years ago just to take a stress test every 3 years, which I generally aced.  I did see my GP on a yearly basis. Several GPs have told me in the past that I had MVP but previous echos (longer than five years ago) showed no sign whatsoever. I even took a stress test and echo from another cardiologist about ten years ago and he saw no valve problems.

For the last 30 years I have been compaining to my cardiologist and other cardiologists (and GPs) about an arrhythmia I felt on occasion.  But we could never catch it on Holters. I suspect it was afib though at the time I was reassured it was likely harmless PVCs. Apparently, some time 3 years or so ago, the PAF advanced to the continuous stage and it was finally detected on an ekg. About 3 months after I was cardioverted and back in NSR, I had a stress test and echo.  It was at this point that the enlarged atria and mild MVR were noted (though, apparently, earlier echos did show an atrial size on the high end of normal). My cardiologist's opinion was that the enlarged atria was caused by being in afib continuously for several months and high BP (even with meds I had an BP of about 140/90 for a decade or more because I refused to take a diuretic - -stupid decision huh?--was afraid that running to the bathroom all the time would interfere with my life-- as it turns out, I seem to go less often now that I'm on HCTZ, especially at night, and now my BP is 120/80). About six months after the first stress test/echo I took another set and there were no changes noted.  I was disappointed at the time that the left atrium size had not decreased as was expected. My cardiologist didn't seem concerned.

But the possible connection between the MVR and the enlarged LA has been weighing on my mind since. For some reason, it never occurred to me (before reading this thread) that the echo might not have accurately assessed the severity of the MVR.

I'm seeing my cardiologist next month. He was planning to do an echo/stress test to keep an eye on my mitral valve and LA. I'll mention that I'd like a TEE as well and see if he goes along with that.

Thanks again!

Regards,

Tony

[Momto3]

Hi Tony,

I was told that mitral valve surgery is seriously considered if the above mentioned criteria are occurring. I had the same experience as Barbarella in that an echo was not sufficient to diagnose the proper amount of leakage. Apparently, all of the clips contained ectopics and the pictures were "fair."  The TEE was able to provide up close and personal pics of those pesky valvs.  Does your doctor perform serial echos to monitor for any changes?  Have you ever had a TEE?  

My doctor has said that BP control and serial check ups are important for watching for any changes in the atria as well as any sign of decreasing function of the left ventricle (EF).  If I remember correctly, she said that a-fib is a bit more prevelant (and significant) in patients with mitral regurg.  Has your doctor mentioned that?  Were you in a-fib at the time of your echo?  I have not experienced A-fib and I am very thankful for that.  From what I have read, it can be tricky to manage and uncomfortable for sure.

I do agree that the criteria have greater significance if you have severe MVR.  

Good luck!!
connie

[hankstar]

Please see my post to you under ablation procedure, I posted it under the wrong thread, got my wires crossed again. I swear I am losing it!

Regards.

[Erik36]

You are correct in that "Lone A-Fib means there is no cause for the A-Fib that can be identified. Also, I too was under the impression that the Cardizem was for rate control during episodes but I have heard a few things from Cardiologosts that Cardizem may be able to prevent A-Fib from starting in some individuals. take care.


Erik

[va_tony]

Wow.  There are a number of interesting discussions going on simultaneously in this thread!

Uptowngirl.  You asked about cardizem for afib. My impression is that cardizem is used mostly to treat high blood pressure and it's relatively ineffective in preventing reoccurances of PAF. It's likely the cardiologist prescribed this for you to lower your heart rate and so tolerate episodes better when they occur. Still, if it has prevented a reoccurance for you and Erik, then great! I've been on 240 mg/day cardizem for many years for high BP but, unfortunately, it didn't prevent me from going into continuous afib a few years ago. Since then I added Rythmol, which was started in the hospital, and the afib now is under control, though I still have self-terminating episodes every couple of months.

Erik. My understanding is the the term 'lone afib' doesn't refer to the number of incidents (e.g., one) but to the fact that there doesn't appear to be an underlying cause (say enlarged atria, MVR, high BP, etc.)-- it's just another way of saying idopathic afib.

Barbie.  I'm sure glad you asked the question about the timing of mitral valve surgery.  I was diagnosed with "mild MVR" with an echocardiogram a few years back. My cardiologist has told me it's nothing to be concerned about and that he'll keep an eye on it.  However, I already have three of the four criteria that your doctor mentioned that indicate valve surgery is needed - afib, enlarged atria (LA dia. of 5.2 cm) and ankle swelling on occasion. Presumably these criteria have greater significance if you have severe MVR and not just mild MVR. However, just reading over the thread's discussion on this topic now has me worried that perhaps the "mild" regurgitation could have been misdiagnosed, especially after Barbarella mentioned that a TEE was needed to accurately determine MVR "severity". Does anyone know the reliability of a standard echocardiogram to accurately assess MVR severity? In particular, does it sometimes happen that one is diagnosed with mild MVR when in fact the MVR is severe(several have mentioned the opposite case)?? Any opinions would be welcomed!

Regards to all,

Tony

[Barbarella]

Hi Barbie,

I know what you went through.  I was so nervous I was not even sedated after all the stuff they put in my veins.  I felt everything, but wanted to get it over with.  I closed my eyes and pretended I was asleep.  Maybe they knew that I wasn't asleep, maybe they didn't.  But they went ahead and did the procedure.

If I were you I'd ONLY pay attention at the result of the TEE test.  This test is a lot more accurate than the echo.  Your TEE test showed "mild".  If I were you I'd not worry about it.  I'm not worried about mine.  I had mine done by a very good Cardiologist in a big "Heart and Lung" hospital, and he told me and my husband "not to worry, I don't even need a follow up".  I know doctors can make mistakes, but I've to trust a Cardiologist who does this procedure frequently that he knows what he is doing and what he is talking about.  I don't think he'd put his signature at the end of the dictation of the result of this test if he were not sure.  There are to many malpractice suits out there.  If this was a very new "experimental" procedure I might would worry more, but this Test has been around for a long time. And the Cardioligists are doing these tests very frequently.

I admit, that at the back of my mind I think like you and wonder will it some day get worse?  But that same goes for my arteries.  I sometimes think "I wonder if and how much they are blocked".  Of course I could get a heart scan for $450.00 to see if I have calcifications or blockages, but I rather not know.  All I would do is worry my head off.  I know of a person who had a 90% blockage in one artery for 20 yrs, he refused bypass because he was scared, he never had a heart attack and died at the age of 78, he had Parkinson's when he died.  My boss's sister in law died in her sleep at the age of 34, NO heart problems, never a day sick in her life.  An autopsy which they did not have done might had shown why she died in her sleep.

[Erik36]

I was started on 180mg of Cardizem at the time of my episode and I have stayed on that dose for three years now. What you and I had was probably Lone A-Fib. It may never come again. Thank God!!

Erik

[pms_barbie]

Sorry it took me a while to answer .  Yes I had a tee done in June.  It said only mild  I think its a 1+.  The tee wasnt fun at all:(

[Dynomite]

I live in NYC and 6 months ago I saw the head of thorasic surgery at NYU Medical center.  He is very well known.  He scared me to death.  I had the feeling he would have operated on me right then in his office.  I am sure that one day I will need an operation but the thought of going on bypass and having open heart surgery terrifies me.  According to every ekg I have taken in the past 10 years my heart is in perfect condition.  I only found out less than 10 years ago about MVP at that time it was minimal however mine has progressed. I go for another echo on Monday and hope for the best.  I have had a tee in May and a thalium stress test in July.  MY cardio was very pleased with the stress test results.  It showed I got my heart up to 85%and my pressure never rose.  If I had not gotten a terrible migraine I would have gone longer than the 12 minutes on the treadmill.

[uptowngirl]

Hi.  Thanks for your response.  Wow, that's great that you've been in sinus rhythm for 3 years. That is encouraging to me.

Yes, I was somewhat concerned (alright, maybe alittle scared!) of going back into that rhythm again, however, I'm comin up on a year here in a couple of weeks, and hopefully I'll stay that way forever.  My Dr. says I'm on a tiny dose (120mg) but it appears to be working well.  I started on a higher dose, but it dropped my BP too low (88/58).  Just curious to know what kind of a dose you are on??

Thank you,
Uptown

[hankstar]

A redundancy of the mitral valve usually mean that leaflets are excessively thickened and floppy,(lets look at it like this some persons have thick lips and others have thin lips) Look at the redundant leaflets of the mitral valve like thick lips. It is usually associated and occurs in MVP, others can apparently have a redundancy of the mitral leaflets without MVP. I have been told I have a a redundancy of the mitral leaflets but no frank mitral valve prolapse or no leakage whatsoever.

Your case is different if you have moderate to severe regurgitation, surgery might be required , as I far as I am made to understand the slightest change in your heart such as left atrial enlargement or dilation the ventricle would warrant surgery, it is always best to have surgery before damage starts.

Trust your doctors to advise you accordingly, if in doubt get an opinion from a reputable center that specializes in mitral valve repair or replacement.

Good luck.

[Erik36]

What a coincidence! I had one episode of A-Fib three years ago and was put on Cardizem to prevent future episodes. I had already been taking the Toprol for years for PVC's and PAC's. Even though I have never had any more episodes my doctor also kept me on the Cardizem to prevent another episode of A-Fib. I also space out the Toprol with the Cardizem. I take the Toprol in the AM and take the Cardizem in the evening too. I exercise frequently and I have very good exercise tolerance. Maybe it is from the Cardizem. The cardizem must prevent the A-Fib from happening.                                                            
Once you've been in normal Sinus Rythm for a year it feels great. Now that I've been in it for more than three years I feel almost as safe as I did before the first episode. I kind of had a dark cloud hanging over my head during the first year. I was so afraid that I was going to go back into A-Fib. Did you feel similar? I swear I thought I was dying when I went into A-Fib. Let's stay out of A-Fib permanently!

Erik

[Dynomite]

Could someone please tell me what is redundancy of the mitral valve.  I have MVP with moderately severe regurg.  six months ago a cardio told me I needed to have the operation.  I went to 6
other cardios for opinions.  The majority all thought as my left vent and left atrium were not enlarged and I do not need an operation right now.  I am having anither echo on Monday for my 6month check up and would like to ask my doctor about redundant mitral valve as soon as I know what it is.

[uptowngirl]

Hi.  I've taken atenelol for almost a decade for the associated palpitations and PVC's that seem to accompany the moderate MVP. I've only been taking the Cardizem for a year and that was because I had an episode of A-Fib last December (I thought it was just stress/holidays).  Even though I've never had another episode like that, the Dr. said I should stay on it for preventative reasons and cut back the atenelol to 25mg.  I guess the Cardizem prevents A-fib from re-occuring.  Does that sound correct?  Anyway, I take the atenelol in the A.M. and the Cardizem at night. That works out fine.  Do you space out the beta blocker and the channel blocker?  I also notice the Cardizem gives me better exercise tolerance.  Have you noticed that?  Thanks so much.
Uptown

[hankstar]

Your echo would be termed essentially normal, having a normal sized ventricle and no trace or trivial regurgitation of the mitral or tricuspid valve, which even if you did have a trace, that in itself is considered a normal finding as 20-30% of the population would show this on echo, with a normal ejection fraction of 60%, which in some institutions normal ranges from 50-70% and 55-75% in others. On the whole there is nothing of clinical significance on your echo. It is completely normal.

Please note this is my understanding only of the information you provided , your doctor could advise with much more reassurance. I have medical background , but I am not certified MD., always trust your doctor, if not that is what second or even third opinions are for.

[hankstar]

Hi,

   That is exactly how my PVCs occur they wax and wane ,sometimes with years in between episodes, then "bang" several a minute for weeks to months, but they tend to occur more frequently at a higher heart rate, maybe this is why beta blockers such as atenolol is effective in suppressing them in my case.

  I almost hate to say this , but your PVCs are probably what is known as vagally mediated PVCs, occuring at a slower heartrate due to your conditioning and high vagal tone, of course that is no reason to stop exercising as the last of exercise has an adverse on your overall cardiovascular health whereas, the PVCs in your case doesn't.

  Do you find yourself feeling fainty in crowded or heated room or even sometimes in a warm shower?

  Take care, my guess would be you have nothing to fear.

Best wishes.

[hankstar]

That should read the lack of exercise , not the last of exercise.

[dafan]

Thanks Hankster. Well ive only been taking the Atenolol for 1 day so i dont guess it has had time to produce any side effects. Youre probably right, im not sure that the drug will work for me. I know it sure had me dragging this morning. Thank you so much for your input here. The support and encouragement and sharing of experiences makes this place wonderful.

[dafan]

Hank, Just one more question. When they send you the report of your echo in the mail it isnt very specific. Mine just stated no effusion, Mitral and tricuspid valve normal, Ef of approximately 60% and ventricle size normal. I requested a followup appointment and was going to ask about the actual values but he stated very emphatically that there was nothing at all wrong with my heart. If you had some subtle things going on would the actual report state that even tho the card they send you says ...normal??

[NBCT]

Just some info. on Tylenol PM. It does work well and is non-habit forming....but the sleep aid in it is Benadryl which can cause a feeling of anxiousness and tachycardia in some individuals. My heart would race after taking just one and I have MVP with freguent PAC's and PVC's.

[Momto3]

Dafan,

Not sure your post shound have been directed at me.  I have MVP and 2-3+ regurgitation of the mitral valve, but am not a candidate for surgery.  I've had the mvp/mr for over 20 years, including through 3 pregnancies - no problem so far.  I have some thickening of the leaflets, but all in all, I am doing OK. Doctors watch closely for any changes.

I HAD pvcs for over 20 years. Holters indicated 24% of my beats were ectopic (ventricular, no atrial), thousands of couplets, too many bigeminal cycles to bother counting, and some nsvt. They didn't really scare me, probably because I had had them for so long, it was kinda "normal for me. Getting used to a regular rhythm was actually weird.  But for the cardiomyopathy, I'd still be "living with them." I was fortunate in that I'd had them for all of my adult life, so I was not afraid of them.  Now, the leaky valve- that's a different story.  I'm hoping that if and when the time comes for surgery, a repair is possible.  

If I remember correctly, Tenormin is the generic RX for atenolol. If that's right, it didn't work for me. Took one dose and was taken off because of a systemic reaction.  However, many others on this board have had great relief with atenolol.  My symptoms were better controlled with Inderal.  I took it on/off for years to combat the frequent pvcs, but in 1998 when I was convinced the pvcs were not going to hurt me, I weaned myself off of it (with doctor's approval) for good.  

When I later developed a cardiomyopathy, I had 2 alternatives: antiarrthymics or ablation(s). Tried the RX for several months, and finally opted to try ablation(s). Fortunately I have a team of great doctors and the procedures were very successful. My heartbeat is rhythmic and the CM has resolved.  

Yes, they definitely waxed and waned (for whatever reason).

Hope you are feeling better!

Barbarella,

I had a similar experience with a routine echo in 2000. Echo suggested "at least moderately severe" regurg. I was sent for a TEE for clarification.  Result was mild to mod regurg.  My dr. said that b/c of hemodynamic changes and individual interpretations, regular echos are subject to a range of interpretation. I just ran into the same thing last month.  The interpreting physician said "severe," but when my test result was compared to others from 2000 - 2003, nothing had changed. Therefore, the TEE performed in 2000 (considered the "gold standard" for assessing valvular disease) was used to clarify the objectivity in interpretation. Glad I had that done : )  

Glad to hear of your good report!!

Connie

[hankstar]

NBCT is absolutely correct,(It contains diphenhydramine(Benadryl) the actual sleep aid in Tylenolol PM. PLease note persons with a prolonged QTc interval should avoid Benadryl(diphenhyramine) it can cause dangerous arrhythmias in persons with this condition and should be avoided. For other person it is generally safe, but can aggravate palpitations in person prone to them.

[Barbarella]

Thanks hankstar for telling me about the Tylenol PM.  I don't take it very often only if I had a really stressful event.

Mom to 3,

I know what you mean about "glad you got that test behind you".  But I was glad they had this test otherwise I'd believe that I had "severe mitral insufficiency".  Anything that has to do with heart and BP freaks me out.

[uptowngirl]

Hi.  Thanks for the info.  You have a wealth of information.  I guess I am glad I'm not in the health profession, but in the teaching field.  Although sometimes I research things to death!

I have only had 2 abnormal ECG's  in my life, but neither had to do with the prolonged QT interval that you mentioned, so the answer would be no.  Although I'm not quite sure what the prolonged QT situation is all about.

I also take atenelol, (and cardizem).  They have been friendly drugs for me, very few side effects.
All the best,
Uptown